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Home My WebLink About4-15-230 0 ~~ sE~~~~r1 ~~ F HOME OF PELICAN ISLAND Certificate # 1933 Certificate of Interment Rights 1N ACCORDANCE with provisions of the Code of Ordinances of the City of Sebastian, it is hereby certified that: Carolyn J. Vernon (name) (name) 705 S. Easy Street, Sebastian, F1 32958 (address) (address) in and for consideration of the sum of $ 7 0 0 . o o ,has purchased and is entitled to full interment rights in the Sebastian Municipal Cemetery for the following plot: Unit 4 ,Block 15 ,Lot(s) 2 3 of the Sebastian Municipal Cemetery, as maintained on file in the records of the City Clerk for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. CONVEYED THIS 31 day of December ~ 2003 C OF SE ASTIAN, ORIDA ATTEST: ~ ~ ) (~C.~.~C.~~~~,~I'I ~. Terrence R. e ~ r Sally A. Maio, CMC City Manage ~ City Clerk Li January 5, 2004 Carolyn J. Vernon 705 S. Easy Street Sebastian, Fl 32958 Dear Mrs. Vernon: Enclosed is City of Sebastian Certificate Number 1933for the purchase of Lot Number 23, Block 15, Unit 4. Also enclosed is a copy of your receipt and the Rules and Regulations governing the Sebastian Municipal Cemetery. If you have any questions, please contact our office. Sincerely, i ~. l ~~~~~ c~ f~ ~ ~ ~,~~ ally Mato, CMC City Clerk SAM:ar enclosure ~~ ~~~~ ~. ~ ~ _ ~ 1 X33 HOME OF PEUUN 151MID City of Sebastian Municipal Cemetery Purchase Receipt To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate regulations, residence of purchaser or person for whom lot is intended for interment must be provided at time of purchase Name(s~ Address ' Area Code & Phone Number Residence Address of Intended Occupant if Other Than Purchaser Office Use Only Rece' t is acknowledged in the sum ~ ~ ~ ~ _~ Dollars (~ oe. ~' ~ ) on this day of , 20oj for the purchase of the following described Cemetery Lot(s) and/or Niche(s). Unit ~, Block /,~ ,Lot(s) ~~ Niche(s) for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed therefore by the City of Sebastian. Additional Fees paid at time of purchase: Corner Markers (set of 4 - $20) Opening & Closing /.?.~ o o W O H Circle One Vase and Ring for Niches (cost) Interment ~Gg Disinterment ~j_ Signature of Purchaser City of Sebastian Service fees are to be paid at time of need only 1:1W W-DATA\Ms-CemeterylRECEIPT.doc FLORIDA DEPARTMENT OF HEALT State of Florida, Department of Health, Vital Statistics APPLICATION FOR BURIAL -TRANSIT PERMIT C~Oo p~ Name of First Middle Last Date Month Day Year Deceased Gary Louis Vernon of Death Dec. 29 2003 Place of Death Ciry, Town or Location County Indian River Vero Beach Name of (If neither, give street address) Hosp. or Inst. Indian River Memorial Hos ital Name of Medical Address Phone Number certifier Gar Silverman, .D. 777 37th Street, #D103 Medical Examiner Physician Vero Beach, FL 772-770-0500 Name of Funeral Home/fir Address Fla. Lic. No./Reg. No. Phone No. (Area Code) 1623 N. Central Ave. Establishment Sebastian, FL 1228 772-589-1000 Strunk Funeral Home Check a. ~ The medical certification has been completed and signed. A completed certificate of death accompanies this Appropriate application. Box b ~ Danielle was contacted on 12/29/03 He/she verified that this death was from natural causes, that there was no accident nor other external cause of death, and that Dr. Silverman will complete and sign the medical certification of cause of death within 72 hours. c, ~ was contacted on . He/she verified that ,Medical Examiner, will complete and sign the medi certificati cause of death within 72 hours. Funeral Director/ ~ Si r F.E. No./Reg. No. Date Signed 1862 12/29/03 BURIAL -TRANSIT PERMIT Permission is hereby granted to dispose of this body. Permit No. 1228-03-0536 ~A five (5) day extension of time for filing the death certificate (exclusive of weekends) has been requested and granted since the physician has been contacted by~the funeral director and will not be able to complete the medical certification of cause-of-death section of the death certificate within 72 hours. ~No extension of time for filing the death certificate has been requested. R~_. Date Date Certificate SubregistrarSignature /~ C~~ Issued: 12/29/03 Due: 1/2/04 AUTHORIZATION -for CREMATION, DISSECTION, or BURIAL-AT SEA Approval Number: Date Medical Examiner, ,gave authorization by telephone to Funeral Director/Direct Disposer. Date The Medical Examiner's approval must be obtained before disposal by any of the above methods. Awaiting period of 48 hours after death is required for all cremations. CEMETERY OR CREMATORY Method of Disposition: Place of Disposition Sebastian Cel/meter BURIAL ~ STORAGE Date of Disposition ~~' ~ ` ~ ~ ~ ~t, Q. f` , CREMATION ~ OTHER (Specify) Signature of Sexton 1 o arson-in- her a Jr is permit must be endorsed by the Sexton or person-in-charge (or by the Funeral Director/Direct Disposer when there is no Sexton) and returned hin 10 days to the local County Health Department in the county where disposition occurred. Distribution: White: Cemetery or Crematory 326, 8/97 (Obsoletes all prevbus editions) Yelbw: Funeral Director or Direct Disposer Kk Number: 5740-0060326-2) Pink: Local Registrar Name ~.:3' ~ fi~ ;~ ~ . ~! ~/`2 1~ ~ ~ ~ A~ v ' ~~'iA~~ Unit Block Lot Date of Mark-out ~ ~ ~` _ ~` ~ ~ Date of Burial ~ ~ ~' ~~-, P" ~ ~~ ~"~ Time ~ ~, ~ ~ ;f / ..~~ Name of Funeral Home `~ ! ~ u `~~ ~ ,~, Authorized by s~--'"" 'r~'`"'""~ -~ $ g g ~ ~ ~ ~ Q ~ ~i ~ `~ y~~~c ~ ~ _ ,,S' o ~ T ~ ~ ~ ~ ~~ M ~~* ~ i •~l~ Y ~, 4 LS ~\ 9~ - - SY ~,